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Stabbed In The Chest

Rob Orman, MD and Chris Hicks, MD
00:00
26:05
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
00:00
06:47

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EM:RAP 2016 April Written Summary 693 KB - PDF

Trauma team leader Chris Hicks walks us through his step by step process of managing patients with penetrating chest trauma.

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Sean D. -

Great segment guys, thanks. What about performing an ED thoracotomy at a non-trauma center? You guys touched on this a little, but wanted to know your thoughts on cracking the chest if you dont have a trauma surgeon at your shop. Does it all depend on local protocols? If your patient fits into that 30% that is salvageable can you transport your pt with an open chest to the nearest level 1 trauma center?

Rob O -

Hi Sean, here is Dr. Hick's reply...
if you have a potentially survivable patient (isolated stab to chest, VSA < 10 absolutely fits this category), and you have reasonable access to a trauma centre by way of inter-facility transfer, then the answer absolutely YES. closing an anterior cardiac wound (sutures, staples, foley) and resuscitating will often produce a very stable patient.

points to ponder though:

1. what's reasonable access? I use the LensCrafters rule -- transfer in about an hour (probably not practical if transport times well in excess of that)

2. the ideal incision: give yourself the best shot, the best exposure -- make a clamshell your initial approach; it's probably the ideal technique for the EP who does this infrequently

3. after ROSC -- leave in bilateral chest tubes, close skin with staples, provide adequate sedation/analgesia, don't forget to reverse any single-lung ventilation you've been doing to facilitate exposure

I know there's a lot more to the discussion, and you can't just up and do this in a ED or with a team who isn't familiar with the procedure. but in the end I think the patient-centered approach in young people with survivable injuries this is the right thing to do, and we need to build systems and understanding, including trauma and non-trauma hospitals, to facilitate that.

David H., M.D. (@BritFltDoc) -

Thanks Dr Hicks. What are you thoughts about the approach to a thoracotomy for a non-surgeon ? Left lateral or clamshell for all ?It seems to me that a clamshell, while obviously "dramatic" and a large incision, would give a provider who is probably very unfamiliar with the bloody mess and anatomy, the best chance of quickly identifying the heart and pericardium, and doing a pericardotomy and hole repair. Yet I feel with this approach, the shared mental model and team preparation is EVEN MORE important, as it will be a big mental hurdle for some to overcome and to commit too.
Thanks.

Rob O -

Here is the reply from Dr Hicks...

agree 100%. we are not thoracic surgeons -- why operate in a hole? the clamshell is the ideal incision for the non-trauma surgeon.

also agree that you can't just show up to work tomorrow and do a clamshell; you'll probably get letters if you do. building understanding and relationships with surgeons and shared mental models with your team is as important as the procedure itself.

K.M. -

I was hoping for more deciding factors to do, or not do, EDT at a non trauma hospital.... transfer times vs. surgical help available vs....?

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Stabbed With A Needlestick Full episode audio for MD edition 249:47 min - 240 MB - M4AEM:RAP 2016 April German Edition Deutsche 86:58 min - 119 MB - MP3EM:RAP 2016 April Aussie Edition Australian 32:49 min - 45 MB - MP3EM:RAP 2016 April Canadian Edition Canadian 25:09 min - 35 MB - MP3EM:RAP 2016 Abril Resumen Español Español 102:58 min - 141 MB - MP3EM:RAP 2016 Avril Résumé en Francais Français 50:04 min - 69 MB - MP3EM:RAP 2016 April Board Review Answers 186 KB - PDFEM:RAP 2016 April Board Review Questions 167 KB - PDFEM:RAP 2016 April MP3 324 MB - ZIPEM:RAP 2016 April Written Summary 693 KB - PDF

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